Political Storm Brewing in California

Profession, Schools Face Off Over Oriental Medicine Legislation

By Editorial Staff

Few pieces of acupuncture legislation have generated as much lively conversation as California's Assembly Bill 1943. Introduced by Assemblywoman Judy Chu of Monterey Park, AB 1943 would add support to the existing landscape of acupuncture and Oriental medicine as it is practiced in California and other states where members of the profession have achieved primary care status.

Among the proposed changes, AB 1943 adds the term "Oriental medicine" in some places where there are only references to "acupuncture" for licensure purposes. AB 1943 also protects the "Doctor of Oriental Medicine" title so that it can only be used by licensed acupuncturists in the future. In addition, the bill requires that clinical faculty members have a minimum of five years experience as a licensed acupuncturist in order to supervise trainees, and authorizes practitioners to "administer" and "dispense" certain procedures and services.

The sections of AB 1943 that have sparked the most debate among members of the profession pertain to the amount of training and education required for acupuncture students in certain subjects. The bill specifies minimum training hours for California-approved schools that offer acupuncture programs (3,200 hours for students entering programs between 2003 and 2007, 4,000 hours for students entering programs in 2007) and gives the California Acupuncture Board the authority to revoke, suspend or otherwise place "conditions" on any school or college that fails to meet such criteria. The regulations would represent an increase from both the current average of 2,970 hours and the 2,348 hours first required in 1985.

Because of the potential impact it could have on acupuncture and Oriental medicine training programs not only in California, but throughout the U.S. and even internationally, Acupuncture Today contacted executives from several schools and state and national organizations to provide their opinions on the significance of AB 1943, and to state whether they favor or oppose its passage. Statements from these respective organizations follow below.

The bill is a totally unnecessary response to some old problems. I think it is obvious to all schools (that) we are doing a good job handling the profession - especially with the national accreditation commission. There has been no reputable evidence that any of the points in this bill are needed or required.

JoAnn Tall, LAc, DOM President

Pacific College of Oriental Medicine - San Diego

Since the safety record of Chinese medicine in California is undisputable, I think the legislation proposed is misplaced. Any increase in hours in schools should be market driven. That is, it should be based on demand from students and patients. Some schools have responded to that, and other schools, using their best judgement, have not. That is the way educational standards should be developed in this profession.

Jack Miller, LAc, MA (Ed) President

Editor's Note: The following is a copy of a letter sent from CCAOM to Assemblywoman Chu on February 26, 2002.

The Council of Colleges of Acupuncture and Oriental Medicine (CCAOM)

Dear Representative Chu:

We are writing to you on behalf of the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), a national organization representing 45 colleges of acupuncture and Oriental medicine located throughout the USA. We have 24 CCAOM member colleges plus two branch campuses that are California-approved.

We would like to meet with you in Sacramento on Thursday, March 7, 2002. Lixin Huang, President of teh American Colelge of Traditional Chinese Medicine in California, will call your office this afternoon or tomorrow to set up an appointment.

We are writing to request that you withdraw your proposed bill AB 1943. There are several very significant problems with the proposed bill. Most importantly, passage of this measure would be very detrimental to the California-approved colleges, our students and ultimately the consumer of our medicine, our patients. The reasons for our request are as follows:

There is no demonstrated need to raise the hours. Our graduates are very competent, patient satisfaction is high, and the field's safety record in California and nationally is superb.

The adverse financial impact on the students, colleges and ultimately the patients would be very significant. From an initial analysis, the proposed increase in hours would cost students at all California-approved colleges at least $12 million, which will impact not only the ability of students to pay their educational loans, but may also make the education in this field beyond the reach of financially disadvantaged students.

State licensure laws are designed to set the basic entry-level standards into a field, not the most advanced levels. Entry-level for acupuncture and Oriental medicine in the U.S., as recognized by the U.S. Department of Education, is the master's degree. A 4,000-hour acupuncture/Oriental medicine educational training program leading to a master's degree is extremely unreasonable and inappropriate. It may also adversely impact the ability of California colleges to attract students who intend to practice outside of California, as all other states use national standards as their main criteria for state licensure. Currently, many students at California colleges are from throughout the USA.

We acknowledge that the hours could be raised and have suggested a 2,600 to 2,800-hour compromise with the practitioners who are attempting to raise the educational training hours. A 2,600-2,800-hour master's program, while eing quite lengthy, might be acceptable.

The practitioners who are recommending the raise in educational training would not themselves have to meet the new educational standards, nor have they agreed to do so. We believe that they should be.

Furthermore, it is very important to emphasize that we are training practitioners in acupuncture and Oriental medicine, not in Western medicine. Students learn a sufficient amount of Western medicine to do a limited biomedical assessment and know a) how to communicate with Western medical providers and b) when to refer patients to Western health care providers. For clarification, it is important that you understand that our practitioners do "acupuncture and Oriental medicine diagnosis and treatment."

The Department of Consumer Affairs rejected the same proposed raise in hours last year due to the lack of demonstrated need and financial support.

The Joint Legislative Sunset Review is in process now, and this bill appears that it is attempting to override that process.

As you probably know, since your husband sits on the California Acupuncture Board, the California Acupuncture Board currently has an Educational Task Force discussing competencies, subject matters and training length, and this bill appears that it is attempting to circumvent the sunset review process as well. We are also concerned that because your husband sits on the Acupuncture Board, that your bill may be viewed in a different light than a bill introduced by someone not related to a board member.

Forty-one states plus Washington, D.C. utilize national standards. Only California does not. We strongly recommend that instead of AB 1943, that California adopt national standards as the primary basis for licensing acupuncture and Oriental medicine providers. The two main national criteria include graduation from an accredited/candidate college and passage of the national certification commission. The national accreditation commission has established the appropriate educational training requirements for our field.

In addition, the colleges do not support the proposed AB 1943 as it micromanages our educational training programs and thus restricts our academic freedom.

There are several other major problems with this bill.

Therefore, we request to meet with you on March 7, 2002 to further discuss this situation. We will contact your office this week to confirm an appointment time.

The AAOM supports the efforts of state professional organizations and the rights of self-governance in each and every state. Since California acupuncturists are licensed as primary care providers and there are no primary care medical professions with less than 4,000 hours as a baseline for entry-level skill sets, we also support the level of professional development Assembly Bill 1943 represents. Let California set an example for the rest of the nation.

No other profession has input into legislative processes from schools or accreditation agencies. This would be the equivalent of WASC or the UC system stepping into medical or legal legislative issues. It doesn't happen. The profession has grown to the point where it is no longer necessary for decisions to be made by educational institutions. Let the profession govern itself.

California Certified Acupuncturists Association

The California Certified Acupuncturists Association is in strong support of Assembly Bill 1943. Since the early days of our history, our organization has always worked toward establishing a health care profession here in this country analogous to that which has existed for centuries in China as practitioners of traditional Chinese medicine. We continue to request to the government to raise the educational standards here so that they more accurately emulate the education that is required in China to practice our art. Assemblywoman Judy Chu's bill takes us one step closer to our goal, and for this, we thank her.

Jackson Chau, LAc President

Editor's Note: The following is a copy of a letter sent from NBAO to Assemblywoman Chu on March 1, 2002.

National Board of Acupuncture Orthopedics (NBAO)

Dear Assemblywoman Chu:

I am writing to you in strong support of AB 1943.

I am the Chair of the National Board of Acupuncture Orthopedics, presently the only board-certified specialty program in the acupuncture profession. NBAO was originally started because acupuncturists in California were admitted to the worker's compensation system as physicians in 1988 and needed to upgrade their standards.

I have personally taught licensed acupuncturists and students in this field since 1990. Our program continues to thrive and prosper, not only because of its academic excellence, but because it fills a large gap in the core education of acupuncturists who practice in California as follows.

California Business and Professions Code, Section 4926, states:

"Also, as it effects the public health, safety, and welfare, there is a necessity that individuals practicing acupuncture be subject to regualtion and control as a primary health care profession."

Acupuncturists receive very little training in primary care. They are poorly prepared to communicate with medical doctors, osteopaths and other health care providers. This has led to isolationism and a strong need to increase the level of public safety where Oriental medicine is concerned.

As I am sure you are aware, there has been an exponential rise in the public's choice of alternative medicine in recent years. The profession is now at a crossroads: either regress backward to remove the primary care designation, which would lower the standards in the profession, or move forward: raise the standards of education, enhance the diagnostic skills and interprofessional communication levels, thus improving public safety. I strongly recommend the latter, and I applaud your efforts toward this end.

I invite you to attend our next class on March 22-24 at St. Vincent Medical Center in Los Angeles to hear what acupuncturists who practice in our state have to say about their education levels and the level of care they wish to deliver to their patients. They feel frustrated and inadequate. They are completing a 300-hour program on their own volition because they feel the need to comply with their own state laws and they wish to deliver the highest standard of care possible. Our program has quadrupled in size this year because of the gap in their core education. I applaud your efforts in raising the bar of (acupuncturists') education to the same level as medicine, osteopathy, chiropractic, dentistry, podiatry and other primary care professions have. It is high time.

Sincerely,

Fred Lerner, DC, PhD, FACO Chair

California State Oriental Medical Association

The California State Oriental Medical Association (CSOMA) is in strong support of Assemblywoman Judy Chu's bill. This bill will raise the California acupuncture educational standards from their 1980s levels to better reflect the increased scope and responsibility of the profession over the last two decades (i.e., workers' compensation). Opposition to this bill on the basis of maintaining homogenous national levels is misguided, as "acupuncture" as defined by the California legislature is significantly different from "acupuncture" as defined by most other states. One needs only to review the law to see this.

Howard Kong, LAc President

American Association of East-West Integrated Medicine

The American Association of East-West Integrated Medicine supports AB 1943, but is concerned that the legislation does not go far enough. We feel that the legislation should make 4,000 hours the educational standard along with the title "Doctor of Oriental Medicine" so that patients know what we practice. A master's degree and "Licensed Acupuncturist" title does not describe what we do. Patients do not call us "master" or "Mr. Acupuncturist." They call us "Doctor" because of respect and what they expect from us. Long ago, we were once "certified acupuncturists," and we needed a doctor's referral. In 1979, the doctor referral was removed. In 1981, our scope of practice was increased, and we were made into a primary care profession. "Acupuncturist" was good before that, and may still be good in states where we can only practice acupuncture. We practice more that just acupuncture in California. Chinese herbal medicine is very difficult to learn, and it can make patients more sick if the acupuncturist does not know enough. Some herbs can be very dangerous when prescribed for the wrong patient. As teachers, we find that students need much more clinic practice, and we recommend at least 1,500 hours of clinic, so that all graduates become good and respected practitioners. We support AB 1943, but recommend more training.

San Hong Hwang, LAc, OMD President

Association of Korean Oriental Medicine and Acupuncture of California

We support AB 1943 to increase the Oriental medicine curriculum in California. The consumers have the right to be treated by competent acupuncturists. A majority of graduates from acupuncture schools indicate that they are not adequately trained to perform as primary health care professionals; that they do not have enough knowledge and skills to take good care of their patients; and that they are not confident in their abilities to treat basic problems. We need higher education to protect consumers in California. Foreign countries like Korea and China require a six-year educational program to be acupuncturists. Chiropractors have at least 4,400 hours of training, and MDs have 6,000-7,000 hours and one year of residency before getting licensed.

Consumers demand advanced knowledge and skills from the acupuncturists. Their expectations increase as the number of patients seeking acupuncture grows. We need to keep pace with patients' expectations. We have to protect the public health. When the legislature eliminated the practical exam two years ago because of computer errors by the exam contractor, they forgot to add extra clinic hours to protect the public, as we recommended. We heard that one acupuncturist has been paralyzed because she did not recognize poisonous Chinese herbs. Another gave a patient herbs in the wrong way, and caused kidney damage. We need better training standards so that all schools teach better. We all have to be competent acupuncture practitioners. Therefore, the educational standard for licensure for acupuncturists should be increased.

Kuk Yul Choi, LAc, OMD President

Yong Sup Lee, LAc, OMD Vice President

California Alliance of Acupuncture Medicine

The California Alliance of Acupuncture Medicine strongly supports Assembly Bill 1943. Raising educational standards will meet the needs of the public for quality health services. Many students complain when they have to take extra classes in subjects that they should have been taught in school before they graduated. We feel that schools should be required to teach a good core curriculum so that every graduate knows enough to practice all of Chinese medicine, take care of patients as primary care providers, and work with other health care professionals. Some schools need better teachers, with more experience in practice.

Maybe AB 1943 should also make acupuncture schools require a bachelor's degree, like medical schools, and passage of an entrance exam, like the MCAT. Maybe students should be required to take basic sciences in college before they start acupuncture school. We support AB 1943 because it tries to improve standards for our profession.

Quincy Chen, LAc, OMD President

United California Practitioners of Chinese Medicine

This letter is written to support AB 1943 authored by Assemblywoman Judy Chu. There is no doubt that acupuncture and Oriental medicine (also called traditional Chinese medicine, TCM) is a safe medical system. But this does not mean that acupuncture is a simple technique or that this medicine is totally without risks. We are using sharp medical devices to penetrate human bodies; we are prescribing many herbs, some of them potentially toxic. We have already seen incidents of pneumothorax and injuries to the central nervous system or internal organs caused by people performing acupuncture without adequate training in the early 1970s. We have also seen the tragedy caused by physicians in Belgium misusing Chinese herbs without proper training - a misuse of guang fang ji (aristolochia fangchi) that cost several patients their lives and harmed many others. Inadequate education was the key reason behind all these tragedies.

We need to train people to become professionals. Each profession has its own standard of qualification. Without such standards, consumers will be at risk. For health care professionals, this is particularly crucial. Let us make a simple comparison: Western medical doctors (MDs) need 6,000 plus hours of professional training; dentists (DDSs) need over 4,000 hours; and doctors of chiropractics (DCs) need 4,200 hours. All prefer a Bachelor's degree before starting their training programs. In China, Traditional Chinese medicine doctors need about 5,500 hours, but our own acupuncturists in California get only 2,348 hours of "required" training. Outside California, they get even less (1,725-2,175)!

We all know that China is still a rather poor country. Its safety standards (water, air, foods and drugs, etc.) are far below we Americans. China faces an ongoing shortage to serve her 1.3 billion people. Despite this need to train a great number of doctors quickly, the Chinese government requires five years of full-time study for its doctors of traditional Chinese medicine. The government considers this the fastest and cheapest way to train a doctor with minimum competency. (Only a few elite colleges are allowed to offer a six- to eight-year course to train higher quality doctors.) In comparison, California acupuncturists now only reach about half of China's minimum standard. Our patients are already facing higher risks than China's patients because of this lack of education. Is the health of Americans worth less than the Chinese? Or it is true only when they need Oriental medical care?

Brian C. Loh, LAc, OMD President

California Acupuncture Medical Association

All national acupuncture organizations (CCAOM, ACAOM, NCCAOM, AAOM) agreed to have a 4,000 hour professional doctoral program back in 1993. Now, CCAOM, ACAOM and NCCAOM support each other to protect their own financia1 interests, and ignore the real standards of acupuncture and Oriental medicine, which we need in California. We want to be a successful primary care profession, so we support AB 1943 because they have waited too long. AB 1943 is a good compromise that will help our schools improve education, before medical schools just take over our medicine.

ACAOM's application fees for accreditation for acupuncture and Oriental medicine colleges average $45,000; meanwhile, accreditation fees of the Western Association of Schools and Colleges are only $3,000. The California Acupuncture Board charges $1,500 plus travel expenses. Why does ACAOM seem to have a higher price for accreditation fees? How can students afford to pay that much money? NCCAOM wants to substitute the California Acupuncture License Examination. NCCAOM would charge $1,650, while the Acupuncture Board only charges $550 for an examination fee. Why does NCCAOM have a higher price for the examination fee?

CCAOM, ACAOM, and NCCAOM education standards are only 1,725 hours, or maybe 2,100 hours with herbs. How can they recommend their education standards and still say they will protect the people of California? This does not make sense.

California licensed acupuncturists are primary health care providers and workers' compensation physicians. Because we have a higher responsibility to protect California consumers' health, safety and welfare, we need higher acupuncture and Oriental Medicine education standards, and have waited a long time.

Ta Fang Chen, LAc Vice President

Coalition for the Advancement of Traditional Oriental Medicine

A lot has changed since 1984, the last time our education standards were determined. With the level and proficiency that our profession is at now, we have been threatened with the loss of our primary care status unless we can assure public safety. This means stepping up our level of training. It is essential to have a solid foundation in Western medical principles, pathology and diagnosis so that we can continue to share the knowledge of TCM/TOM with our patients and other health care professionals. While many schools already provide this kind of training, it is inconsistent, and many take extra classes outside of school to get all of the training they really need.

This legislation is an exciting beginning to 2002 for those of us in the Oriental medicine profession. It is the year of the yang water horse, and the horses are charging out of the gate. We have four bills up for legislative vote this year, the most ever in one year. Please take a few minutes to take action now. Now is not the time to hold your horses. Passing the bills is going to take all of our efforts in concert. The bills are crucial for the future of our profession for many reasons. They will increase our ability to help patients by upgrading our training; provide access to more patients by putting us on equal ground with the other members of the health care system; and mandate that all group health plans operating in California cover acupuncture. They will clarify our scope of our practice, ensure the quality of the herbal medicinals we prescribe, and, as the I Ching put it, "pay heed to the providing of nourishment (for all)."

Eric Reed, LAc President

Council of Acupuncture and Oriental Medicine Associations

The Council of Acupuncture and Oriental Medicine Associations, representing a number of language-based professional acupuncturist organizations in California, is the sponsor of Assembly Bill 1943. Assembly Member Judy Chu graciously offered to author this important legislation on our behalf.

For nearly 15 years, Council representative have consistently participated in meetings, task forces and open dialogues with our profession, schools and the Acupuncture Board. As part of these open discussions, it was unanimously agreed in the early 1990s that there was a need to develop a 4,000-hour first professional doctorate for entry into the profession, similar to other primary care professions in California, and to require a core component of Western clinical sciences for the purposes of effective collaboration with other health care providers, and for the health, safety and economic welfare of our patients.

California started licensing acupuncturists in 1976, requiring a physician's prior diagnosis and referral. Beginning in 1979, the physician diagnosis and referral was removed, and our profession became independent practitioners. A few years later, the Legislature expanded our scope of practice, and granted us "primary care" status. Education was increased to 2,348 hours for those entering school after 1984. MediCal coverage for our services was authorized. In 1989, our primary care status helped us become "physicians" in Workers' Compensation, and 10 years later, "pre-designated" primary providers. In 1995, we were granted protection from court-ordered disclosure (subpoena) for the purposes of confidential peer review just like other primary health care professions. We were allowed to form acupuncture corporations, and later, to become full participants in medical partnerships. Based upon our legal status, individual acupuncturists have been able to gain limited hospital privileges; worked as policymakers in managed care organizations; and generally break down nearly every barrier to becoming primary care peers in the American health care system. What else? The Food and Drug Administration classified needles as medical devices; the National Institutes of Health recognized the legitimacy of acupuncture; and the World Health Organization standardized acupuncture point nomenclature and adopted training and safety guidelines well above California requirements. The majority of health insurance policies in California now cover acupuncture, and require standardized reporting procedures.

The curriculum at California-approved schools is currently averaging nearly 3,000 hours, 300-400 hours above non-California approved schools. California-approved schools are thus charging $3,000-$10,000 for extra coursework above the required 2,348-hour curriculum. While our profession is not suggesting that schools be forced to refund that money or reduce the number of hours they teach, we are suggesting that they take the consistent advice of experts in the field by applying those additional hours to quality coursework that will meet the needs of our widely recognized status and responsibilities as a primary health care profession in California, and give graduates the best chance of succeeding in the private practice setting. By doing so, they would also meet similar standards that have been adopted or proposed in the other primary care states such as Florida or New Mexico.

AB 1943 is designed to put the historically consistent and widespread advice of experts into action, by setting education standards for licensing at 3,200 hours in the year 2007 and 4,000 hours in 2011. We suggest that every acupuncturist and acupuncture student to ask your school, the CCAOM, ACAOM, and NCCAOM to stop spending student tuition and certification fees on lobbying efforts designed to take control of our profession, and instead ask them to join with us in support of Assembly Bill 1943 for the benefit of our patients and the future of our profession.

Brian C. Fennen, LAc Executive Director

Editor's Note: The following is a copy of an "Open Letter to the Profession" sent on March 2.

National Guild for Acupuncture and Oriental Medicine

I was disappointed to have received the e-mail from Elizabeth Goldblatt to specific members of the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) as well as a cc: to Howard Moffett, an appointed member (opposed by every professional association in California) to the California state Acupuncture Board with the appearance of influencing a state official to "through [sic] a monkey wrench into the works by hiring a "high-powered" lobbyist to "get the bill nixed" (referring to AB 1943).

I am also in receipt of three additional letters, the first dated 2/26/2002 from CCAOM members Elizabeth Goldblatt, Jack Miller, Lixin Huang, Shen Ping Liang, Steve Given, Barbara Ellrich and Anthony Abbate to Representative Chu, author of AB 1943, requesting withdrawal of the bill. This bill will assure patients of greater safety, improved training for better effectiveness, and gives acupuncturists educational equity with all other medical providers, thus paving the way for increased participation in the American health care system and enabling our profession to help more people. We are most puzzled as to why · members of CCAOM are opposed to improving our profession and would be most neglectful in our duty to the public and the profession if we did not question their motives at this time.

The second leter is dated 2/27/2002 to Benjamin Dierauf, president of CSOMA from Christina Herlihy, CEO of the National Certification Commission for Acupuncture and Oriental Medicine, threatening possible legal action apparently in response to Mr. Dierauf's letter expressing concern about NCCAOM's proposal that California accept the NCCAOM certification as a licensing standard. It is clear to everyone well-researched in this matter that the NCCAOM certification does not meet California's licensing requirements. This was amply demonstrated and addressed in the California Acupuncture Board's response to the Joint Legislative Sunset Review Committee in November 2001 and the Occupational Analysis/Validation Report 2001, as well as the Task Force Identification of Educational Deficiencies and recommeded curriculum changes by the profession's peer review system.

And last but not least, an odd letter from Jack Miller, president of Pacific College, who believes his program and CCAOM shouldn't be accountable to the state or federal government or the profession, and most importantly, the welfare of the public. Your disrespect for the profession and your students is sad.

I will remind you the reason for forming the California Acupuncture Board's Competencies and Outcomes Task Force is to address the deficiencies in the current curriculum and testing that are not in compliance with minimal entry-level educational requirements. As we approach the next Task Force meeting in April, remember the issues that you have so desperately mis-stated have been addressed and are public record. We have submitted numerous laws and regulations with legal opinions by the California Department of Consumer Affairs concerning our role and responsibility as regulated as a primary care profession within the scope of practice of a licensed acupuncturist. We have also submitted numerous peer-reviewed research articles concerning scope of practice, Chinese medicine, and malpractice issues; thus far, the CCAOM has submitted their personal opinions. We have, as a united profession, had to seek other educational tracks and accreditations needed for us to compete in the market in California and other states such as Florida, Hawaii and New Mexico. We as professionals, business owners and consumers expect you to "step up to the plate" and perform at the minimal competency level that the profession and the legislature require.

We believe it would best serve the students, the legislature, the profession and the public if you would stop threatening the profession and spend the money you waste on lobbying against the profession, and work with us n providing needed education to the students you serve and the public who depend on it.

Ted G. Priebe, LAc, OMD President

The following schools were also contacted by Acupuncture Today prior to deadline, but chose not to provide a statement:

Emperor's College of Traditional Oriental Medicine

South Baylo University

Five Branches Institute: College of Traditional Chinese Medicine

Southern California University of Health Sciences

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